You can’t always get what you want

“Customer service” is the new buzzword in health care. (Yes, I know it’s two words. Stay with me here.) Health care has become a service industry, like a restaurant or a company that comes to your home to replace a broken windshield. The shrimp is too salty, or the tech left footprints on your floor mat? You complain, and you send the shrimp back, and the tech apologizes and says “yes sir” and vacuums out your car. The customer, as we know, is always right.

Except in health care. Administrators and patients don’t want to hear this, but in health care the “customer” is not always right. And pretending that the customer is always right is costing us a whole lot of money and a whole lot of preventable sickness. We’re customer servicing ourselves into crappy health care, and docs and nurses seem to lack the power to prevent this from getting worse.

I’m part-owner of a few after-hours pediatric health clinics. Our sites are open when traditional pediatric practices are closed. Our patients – not customers– see genuine, board certified pediatricians for things like fever or sore throat or cough or ear pain. Common pediatric stuff. Rarely, we get complaints about or service or ugly remarks on Yelp, etc. Almost all of the negative reviews can be summarized like this: “I paid my money, and I didn’t get an antibiotic. I expect my antibiotic. I am the customer, and the customer is always right.” We don’t get comments about whether our doctors did a good and careful assessment, or whether they made a careful decision about recommendations. Nope, the customer is always right, and the customer wants an antibiotic. And if one isn’t given the customer is darn tootin going to complain about it.

We’ve had similar complaints on review sites about my own medical practice: “I brought in my child with a bad cold, and I didn’t even get an antibiotic! Zero stars for you!” I consider not giving antibiotics when they’re not needed – for a cold — a mark of a good practice. But someone skimming the reviews might just choose to go somewhere else. Perhaps a place that sees twice as many patients per hour, because explaining how to treat a cold correctly takes much longer than a quick antibiotic prescription.

It’s not just antibiotics, of course. In emergency departments all over the country, customer service and positive “reviews” are what drives physician salaries and hiring. You don’t make your patients happy, you’re going to take a pay cut or lose your job. But what if your patients – I’m sorry, customers – want something that isn’t good for them, like narcotics for chronic pain? We know narcotic addiction, driven by prescription products, is now the leading cause of accidental death in the US. But once patients become customers, they’re always right. And once doctors realize that negative reviews are going to cost them a job, what do you think is going to happen?

Of course, docs are being squeezed simultaneously in the other direction. The Feds don’t want us to “overprescribe” narcotics, either. They just want us to treat pain, quickly, and without our customers complaining. How exactly to do that is entirely up to us – we’re the doctors, of course, and no one would ever tell us what to prescribe – as long as we don’t use too much of the only drugs that work. Whatever “too much” is. That’s a secret. We’ll just monitor everything you do via your shiny new electronic medical record that you’re required to use. Which you hate. Please, don’t mind us.

One more example: I have here, mailed to my home, a flyer from my health insurance company. (I guess I shouldn’t tell you which one, but they’re huge, and you can rearrange the letters in their name to spell “Aetna.”) They offer a service, Teladoc, which costs “$40 or less”. Available “anytime, anywhere”, you get 24/7/365 access to “U.S. board-certified doctors” to treat things like “sinus problems, bronchitis, allergies” and “ear infection” over the phone! The doc can diagnose and prescribe medication for “many of your medical issues.” All without, you may have noticed, even pretending to do a physical exam. Or maybe they have a really long stethoscope that they can shove through the little tiny holes in their phones, or a 7 mile long swab to do a strep test. These clowns are going to know whether or not you need antibiotics without an exam, without touching you, without seeing you or without even being in the same room as you. That’s not medicine. It’s dark magic.

But you know what? They program will probably be successful. Because we know that many people don’t want a physician’s judgement – they just want antibiotics and prescriptions. So, with a wink and a nod, “Teledoc” gives us exactly what we’ve come to expect. The customer is always right. $40 out of pocket, and you can bet “Aetna”, or whoever they are, is saving some serious money by paying Teledoc next to nothing instead of paying a real doc to do a real evaluation. Everyone wins. Except you.

As philosopher Mick Jagger famously said, “You can’t always get what you want.” And at least in health care, you shouldn’t. Unfortunately, even if you try, it’s becoming harder to get what you genuinely need.

12 Comments on “You can’t always get what you want”

If I saw a review of a doctor that said they are upset because they didn’t get an antibiotic I would consider that a plus and would be more likely to see that doctor. So, maybe, hopefully, it would attract the kinds of patients (or in your case, parents of patients) you’d rather be seeing anyway who are interested in the best treatment as opposed to their misconception that antibiotics cure everything.

I agree- I would look at not prescribing an antibiotic a plus too. My husband went to an urgent care and the PA walked in and asked if he was there to get an antibiotic. My husband said only if I need one. The PA, after a super quick exam, announced that he had strep and he will send the antibiotic prescription and walked out never to be seen again. And he didn’t even bother to do a strep swab and test. We will never go to that urgent care again. I find it frustrating that people are still uneducated about overuse of antibiotics. I’m just an average person and I know better!

At the end of last year, we had relocated halfway across the country. Over Christmas week, I ran low on my beta blockers and my old doctor wasn’t comfortable refilling them, leaving me to run out two days before Christmas (and annoyingly, no word from the office to that effect).
The first week of January, I made an appointment for a doctor that I researched via online ratings, a significant part of the evaluation was *not* “doctor gave me an antibiotic” and more the converse.
On 8 Jan, I had my first appointment and rather shocked new doctor. First presentation, an apparently healthy male, mid-50’s, BP 200/100, pulse 128. Doctor wisely decided upon an ECG and upon ordering the ECG, gave us our walking instructions and RX for refills for our meds and referrals for specialists.
Doctor halted us in the hall, just short of the door and pulled us into a nearby examination room and quite flustered, remarked that we both had atrial flutter. I misheard and thought it was only myself and atrial flutter isn’t uncommon in tachycardia, so I suggested awaiting the effects of the beta blockers and reassess. Doctor concurred.
Blood work gave a new cause for concern, nearly absent TSH.
The next appointment that had a repeat ECG strip, I had a copy ran for “my own records” and was greatly irritated at frank LVH, albeit moderate in amplitude signal and no directional shift, it’d have been nice to have that while assessing flutter, while shocked at learning of it.
Of course, the whole hot mess was secondary to hyperthyroidism.
Upside, doctor didn’t RX pad things away, spent a hell of a lot more time than the insurance companies like with us, as have the majority of the specialists (one who didn’t also failed to fill out the insurance company forms for further services and at his behest, we’ve terminated our relationship with him and found a new neurologist).
First consideration on researching new doctor, “Doctor spent time to…”, insurance companies hate that, but the standard of care is to spend the time, both to get an accurate history, accurate assessment and establish communication that is bidirectional, as well as educate the patient.
Second consideration, “doctor didn’t give me an antibiotic”, if I don’t have a flipping bacterial infection, I don’t want some motherloving antibiotic! I want an appropriate treatment for my illness or stabilization until I can receive definitive care by a specialist or hospital. If I want McMedicine, I’ll go to an urgent care and receive my malpractice and zero continuity of care.
I am not a customer, I am a patient or in the various business relationships, not a casual customer, but a client. A client implies a professional relationship and one where one doesn’t do precisely what the client wants, but what is good for the client.

Honestly, if I have symptoms that leave doctor honestly saying, “I’m really not sure”, I don’t have a problem with that if doctor also says, “I need to read up on this”. Or even check with some buddies, we all can’t be experts in every single sub-specialty in the field. I’m not in mine, my doctor isn’t in his, we call in and defer to the SME in that sub-specialty.
It’s also something I’ve ribbed a few ED docs I know, as they’re notorious for missing fine nuances in a diagnostic image and the staff radiologist catching it. 😉

RE: those of you who would consider a complaint about an rx-stingy doc a positive — I appreciate that, but unfortunately we end up with fewer “stars”. So sorting or skimming the list shorts us. You can find several such reviews of my practice lurking out there. Cest la vie!

Well, doc, there is one RX stingy type I won’t deal with. One who is presented with diagnostic imagery that shows clear cauda equina, with stenosis, secondary to disc herniation and that one is stingy with referrals and pain medication. Especially as that is one of the conditions my wife suffers from, she also popped once with sufficient antibodies to diagnose Lupus (the rest of the time, it does what Lupus does, hit and run).

I agree that antibiotics are overused, and that patients frequently request (or demand) them. But I don’t think “customer service” in medicine is a bad thing, if you think of it as bedside manner. Many drs have a great bedside manner, but some don’t. As a patient, it really annoys me when physicians want you to blindly trust them, but give you no respect in return. I think it is a good thing that people are at least interested in their health, and this provides a way to open a dialogue with the patient regarding health care choices.

Sometimes it all works out right and parents do understand. I saw a girl in follow up today. She was seen by a nurse practitioner in my office for fever and sore throat last week. She had a negative rapid strep, so was told to do symptomatic treatment while awaiting culture. Her strep culture was negative, but the sore throat and fever continued so she went to a local pediatric urgent care after hours. They tested for mono and it was positive. Mom commented today about how happy she was that the NP didn’t just give an antibiotic that wasn’t needed. I thanked her for that compliment, since we usually only hear complaints!

When I picked a pediatrician for my son, I told him he would never just write a prescription for antibiotics to get me out of the office. There are those doctors out there who prescribe for everything. They add to the Healthcare dilemma. They breed patients who think antibiotics should be prescribed for everything. Your 1 yr old doesn’t have a sinus infection! We need to rid ourselves of both over prescribing providers and prescription demanding patients. Darn tootin’!

One time, working as a pediatric hospitalist, I was called in to the administrator’s office: “Mrs X said you refused to prescribe her child an antibiotic”. Mrs X’s child had been admitted with a viral chest infection. She had asked me about an antibiotic and I had carefully explained it would not help. Adminstration was very unhappy with me. It’s all about patient (parent satisfaction). Screw you patient!